Anastomotic leak: an early complication with potentially long-term consequences

Significant improvements in surgical techniques and postoperative care have led to a reduction in morbidity and mortality associated with esophagectomy (1). Nevertheless, anastomotic leak remains the most feared complication and represents the Achilles’ heal of esophageal resection. The overall risk of developing an anastomotic leak is about 10%, with significant higher incidence for cervical anastomosis compared to intrathoracic (2). The impact on overall post-operative morbidity is significant, with increased hospital stay, need for re-operation, re-admission and 30-day mortality (3). The interesting question that Markar and colleagues (4) addressed with this study is the influence of an anastomotic leak on the long-term survival. Previous studies have analyzed the relationship between anastomotic leak and the risk of impaired oncologic outcomes with conflicting results. Escofet et al. (5) analyzed 240 patients who underwent esophagectomy from a regional cancer network in UK and found that long-term survival was not affected by anastomotic leak. Similar findings were reported by Hii and colleagues (6) in a series of 618 patients with no effect of postoperative complications on disease-specific survival. Xia et al. (7) also reported that major perioperative morbidity after esophagectomy did not have a negative impact on long-term survival. On the other hand, Ruteg？rd and colleagues (8) showed that the occurrence of surgical complications was an independent predictor factor for poorer long-term survival in patients undergoing esophagectomy for esophageal cancer. Concordantly, Andreou et al. (9) stated that anastomotic leak following resection for esophageal cancer had a negative prognostic impact on long-term survival, independent from tumor stage. The problem with these studies is the lack of standardization regarding the definition of anastomotic leak. Recently, the Esophagectomy Complications Consensus Group (ECCG) has defined anastomotic leaks as full-thickness defects involving the oesophagus, anastomosis, staple line or conduit, irrespective of the presentation or method of identification (10). In this classification, leaks are divided into three types based on management strategy. Type 1 leaks require no change in therapy, are treated medically or with dietary modification. Type 2 leaks require interventional but not surgical therapy (interventional radiology drain, stent, etc.) and type 3 leaks require surgical intervention. A standardized widely adopted system to record this type of complication is of great value and will help future studies to